By Joseph Sonnabend, MD
Image courtesy of Kevin Thomas/Dallas Voice
PrEP is now being recommended by the WHO for, it seems all, sexually active gay men. Actually it’s not quite that stark – they continue to recommend condom use as well. Despite this, many will probably see this as a recommendation to rely on PrEP as an alternative to condoms.
The WHO recommendation is a population based proposal, a public health recommendation as opposed to recommendations for specific individuals, and as such it is truly perplexing. Recommendations for individuals are different because they take into account individual circumstances, such as the extent to which a specific person is at risk. Population based recommendations are recommendations made across the board, in the case of the WHO, addressed to all men who have sex with men.
While assuring us that the recommendations are evidence based and providing the customary explanation of how the strength of evidence is graded, we learn that the WHO has made a sweeping worldwide population based recommendation on evidence provided by just one randomized study! This was the iPrEx study, which was beset with interpretative difficulties, not least because few took the medication as directed, if at all
We simply do not know enough about PrEP to make a sweeping population based recommendation. We have little idea of what adherence might look like in various populations, we know little about the degree of protection in specific sexual acts. Different sex acts carry different risks, for example, to the receptive or insertive partner in anal sex. Also, how effective is PrEP in situations of exposure to high and low viral loads. So the WHO recommendation that all sexually active gay men consider PrEP is not only remarkable in that it’s supported by such scanty evidence, it’s also offensive because gay men are viewed as so uniformly dangerous that they need to be medicated.
A more balanced response would have been a call for more research, and importantly, for a fuller description of those individual situations where PrEP use may be a rational preventative intervention at the present time.
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